|
zolpidem 5 mg Tab [HMC]
|
Facility
|
IP
|
$18.88
|
|
|
Service Code
|
NDC 13668000701
|
| Hospital Charge Code |
3800683
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.99 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$16.99
|
| Rate for Payer: UnitedHealthcare Commercial |
$17.94
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
zolpidem 5 mg Tab [HMC]
|
Facility
|
OP
|
$18.86
|
|
|
Service Code
|
NDC 51079072420
|
| Hospital Charge Code |
3800683
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.54 |
| Max. Negotiated Rate |
$17.92 |
| Rate for Payer: Aetna Commercial |
$16.97
|
| Rate for Payer: Humana Medicare Advantage |
$7.92
|
| Rate for Payer: UnitedHealthcare Commercial |
$17.92
|
| Rate for Payer: UnitedHealthcare Medicaid |
$7.54
|
| Rate for Payer: WPPA Medicare Advantage |
$11.32
|
|
|
zolpidem 5 mg Tab [HMC]
|
Facility
|
IP
|
$5.31
|
|
|
Service Code
|
NDC 00904608261
|
| Hospital Charge Code |
3800683
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.78 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$4.78
|
| Rate for Payer: UnitedHealthcare Commercial |
$5.04
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
zolpidem 5 mg Tab [HMC]
|
Facility
|
OP
|
$18.88
|
|
|
Service Code
|
NDC 13668000701
|
| Hospital Charge Code |
3800683
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.55 |
| Max. Negotiated Rate |
$17.94 |
| Rate for Payer: Aetna Commercial |
$16.99
|
| Rate for Payer: Humana Medicare Advantage |
$7.93
|
| Rate for Payer: UnitedHealthcare Commercial |
$17.94
|
| Rate for Payer: UnitedHealthcare Medicaid |
$7.55
|
| Rate for Payer: WPPA Medicare Advantage |
$11.33
|
|
|
zzinsulin aspart-insulin aspart protamine 30 units-70 units/mL SubQ Susp 10 mL [HMC]
|
Facility
|
OP
|
$182.06
|
|
|
Service Code
|
HCPCS J1815
|
| Hospital Charge Code |
3800655
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$172.96 |
| Rate for Payer: Aetna Commercial |
$163.85
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$0.27
|
| Rate for Payer: Humana Medicare Advantage |
$76.47
|
| Rate for Payer: UnitedHealthcare Commercial |
$172.96
|
| Rate for Payer: UnitedHealthcare Medicaid |
$0.13
|
| Rate for Payer: WPPA Medicare Advantage |
$109.24
|
|
|
zzinsulin aspart-insulin aspart protamine 30 units-70 units/mL SubQ Susp 10 mL [HMC]
|
Facility
|
IP
|
$182.06
|
|
|
Service Code
|
HCPCS J1815
|
| Hospital Charge Code |
3800655
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$163.85 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$163.85
|
| Rate for Payer: UnitedHealthcare Commercial |
$172.96
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
zzinsulin glargine 100 units/mL SubQ Sol [HMC]
|
Facility
|
IP
|
$173.12
|
|
|
Service Code
|
HCPCS J1815
|
| Hospital Charge Code |
3808637
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$155.81 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$155.81
|
| Rate for Payer: UnitedHealthcare Commercial |
$164.46
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
zzinsulin glargine 100 units/mL SubQ Sol [HMC]
|
Facility
|
OP
|
$173.12
|
|
|
Service Code
|
HCPCS J1815
|
| Hospital Charge Code |
3808637
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$164.46 |
| Rate for Payer: Aetna Commercial |
$155.81
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$0.27
|
| Rate for Payer: Humana Medicare Advantage |
$72.71
|
| Rate for Payer: UnitedHealthcare Commercial |
$164.46
|
| Rate for Payer: UnitedHealthcare Medicaid |
$0.13
|
| Rate for Payer: WPPA Medicare Advantage |
$103.87
|
|
|
zznystatin 100,000 units/mL Oral Susp [HMC]
|
Facility
|
OP
|
$28.14
|
|
|
Service Code
|
NDC 66689003799
|
| Hospital Charge Code |
3800586
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.26 |
| Max. Negotiated Rate |
$26.73 |
| Rate for Payer: Aetna Commercial |
$25.33
|
| Rate for Payer: Humana Medicare Advantage |
$11.82
|
| Rate for Payer: UnitedHealthcare Commercial |
$26.73
|
| Rate for Payer: UnitedHealthcare Medicaid |
$11.26
|
| Rate for Payer: WPPA Medicare Advantage |
$16.88
|
|
|
zznystatin 100,000 units/mL Oral Susp [HMC]
|
Facility
|
IP
|
$28.14
|
|
|
Service Code
|
NDC 66689003799
|
| Hospital Charge Code |
3800586
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$25.33 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$25.33
|
| Rate for Payer: UnitedHealthcare Commercial |
$26.73
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
